INTRODUCTION

Acute mesenteric lymphadenitis is a well - defined entity Dengue fever continues to be a global
concern in subtropical and tropical countries for the past decades where 2.5 billion populations
are at risk.1-6 It is apparently the most significant challenge since 1980s and has become a major
public health concern in Asia Pacific (with 70% occurrence rate), Middle-East, Africa, the
Caribbean and South America.6,7 World Health Organization defines dengue fever as the most
common arthropod-borne communicable disease caused by four flaviviral serotypes through the
transmission by female Aedes aegypti and Aedes albopictus.4
One bite of an infected mosquito transmits any of the four viral serotypes from viraemic to
susceptible humans.3,8 Heymann proposed that dengue fever is also addressed as a breakbone
fever which is characterized by a sudden onset of fever for 2 to 7 days, followed by myalgia,
arthralgia, intense headache, nausea, vomiting and anorexia. Generalized petechial, erythema or
macular-papular rash are commonly present.9 In additional, leukocytopenia, thrombocytopenia
and lymphopenia arise concurrently secondary to the abrupt viral replication and cellular
destruction in the bone marrow.5
Based on dengue surveillance summary, the World Health Organisation has documented an
increase of dengue cases in Malaysia compared to year 2013 and 2014.4 As of 15th August
2015, there were 75,795 cases of dengue with 212 deaths reported in Malaysia. This is 26.8%
higher compared with the same reporting period of 2014 (n=59,790).10

METHODS
A quasi-experimental one group pre-test post-test research design was used to determine the
effectiveness of health education on knowledge of dengue fever and preventive measures before
and after health education among high school students in a selected school in Malaysia. The
target population was Form 4 and Form 5 high school students. Nonprobability convenient
sampling method was used to choose the participants who fulfilled the inclusion criteria.
Inclusion criteria
Form 4 or Form 5 students.
Both male and female students.
Able to understand and read English or Malaysian language.
 Willing to participate in the study.
Not undertaken any teaching session on dengue preventive measures in last three months
period.

Exclusion criteria
Other than Form 4 or Form 5 students.
Unable to understand and read English or Malaysian language.
Unwilling to participate in the study.
Undertaken teaching session on dengue preventive measures in last three months period.

The questionnaire was developed with the guidance from Isa, et al.11 There are 3 parts in the
questionnaire; Part A: Demographic characteristics, Part B: Knowledge on dengue fever and
preventive measures and Part C: Dengue health education exposure. The questionnaire has
multiple-choice questions and participants answered the questions by choosing the most relevant
answers.
Health Belief Model guided this study as it is one of the commonest theoretical frameworks used
in health promotion and health education studies.12 The major objective of health belief model is
to promote health, healthy environment and prevent individuals from harmful illness through
modifiable- predictive theoretical constructs.13 The seven theoretical constructs discussed in this
model are perceived severity, perceived susceptibility, perceived benefits, perceived barriers,
cues to action, motivating factors and self-efficacy (Figure 1).

The pilot study was conducted among 20 participants in a private school. The Cronbach’s alpha
coefficient of the instrument measured was 0.7. The validity of the questionnaire was done by
content experts. The instrument was modified and revised to suit the local context based on their
suggestions. Dengue prevention power point slides were developed under the guidance of
National Agency Environment Singapore.14 A respiratory physician from a private hospital
validated the content of power point slides on dengue fever and preventive measures.
A total of 15 minutes was given to complete the three parts of questionnaire during the pre-test
and post-test data collection. Following the presentation of power point slides on dengue fever
and preventive measures, the same sets of questionnaires were distributed to the same sample as
post-test data collection after 2 weeks.
The research was approved by the International Medical University (IMU) Joint Committee of
the Research and Ethical Committee. Permission was obtained from the private school to
conduct the study. Written consents were obtained from all participants. Participants’ rights to
privacy, autonomy, confidentiality, fair treatment, protection from discomfort and harm were
well preserved.
RESULTS
The data was analyzed using Statistical Packages for the Social Sciences (SPSS) version 22. The
demographic data was analyzed by descriptive statistics. Paired t-test was used to find the mean
difference between pre and post dengue health education. There were 63 participants in the pre-
test while only 60 subjects participated in the post-test due to absence of 3 subjects during the
post test.
Demographic characteristics
The results of demographic data are shown in Table 1. There were 63 participants in the pre- test
and 60 participants in the post- test. Among them, 58.7% were male and 41.3% were female in
the pre- test, while 60% male and 40% female participated in the post- test. Furthermore, 98.4%
of them belonged to Chinese race in the pre-test and 98.3% in the post-test. Indians were 1.6% in
the pre-test and 1.7% in the post-test. In addition, 36.5% subjects in the pre- test were from
Science stream and 36.7% were from Science stream in the post-test. There was only 1.6% and
1.7 % subjects from art stream in the pre-test and post- test respectively. The rest of the subjects
were from other study stream in the pre-test (61.9%) and post- test (61.6%) (Table 1).

Knowledge on dengue fever and preventive measures

The results in Table 2 shows a total of 88.9% subjects have heard of dengue fever in the pre-test
compared to 100% subjects in the post-test. There are 58.7% subjects who claimed that dengue
fever is transmitted by mosquito bites, 30.2% mentioned that it is transmitted through blood,
4.8% mentioned that dengue fever was waterborne and 6.3% subjects had no idea about the route
of transmission in the pre-test. In the post test, there was significant increase in the understanding
about dengue transmission route, where 85% of them mentioned as mosquito bites, 1.7%
subjects as airborne, 11.6% subjects thought that it was blood borne and 1.7% waterborne. The
response to the question on type of mosquito, Aedes mosquito was the highest selection in the
pre-test (60.3%) and post-test (85%). About 35% subjects had no idea about dengue mosquito in
the pre-test in which they demonstrated good understanding about mosquito involved after health
education. Most subjects did not know the mosquito biting time in the pre-test, as 49.2% subjects
thought that 7 p.m. to 9 p.m. was the time duration when mosquito stays active. After the health
education, a total of 85% subjects understood correctly that the mosquito biting time is from 6
a.m. to 8 a.m. and 7 p.m. to 9 p.m. (Table 2).

The response to the questions on signs and symptoms of dengue fever, all subjects chose high
fever in both pre-test (100%) and post-test (100%) followed by deep muscle and joint pain in the
pre-test (88.9%) and headache in the post-test (95%) respectively. Only 6.3% subjects chose
enlarged lymph nodes in the pre-test which shows significance statistically after the post-test (p-
value <0.05). There was also significant difference in the knowledge on identification of dengue
signs and symptoms of diarrhoea, headache, loss of appetite, eye pain and nausea and vomiting
among the subjects after health education (p-value <0.05).
A total of 98.4% subjects chose roof gutter as the commonest mosquito breeding ground in the
pre-test while 98.3% subjects chose flower pot trays as the commonest mosquito breeding
ground in the post-test. About 69.8% subjects thought that there is availability of dengue
vaccination in the pre-test.
Figure 2 shows the understanding of availability of dengue vaccination among the subjects. The
awareness of knowledge on vaccination increased to 82.5% after health education (Figure 2).

About 96.8% subjects relatively agreed that keeping the drain free is essential to prevent dengue
fever transmission during the outbreak in the pre-test and 96.7% subjects chose removing the
water from flower pot trays as the vital aspect to prevent dengue fever transmission during the
outbreak.
The highest rated dengue preventive measures to mosquito bites were usage of mosquito
repellents and mosquito bed nets followed by wearing long pants respectively. Nevertheless,
wearing socks and wearing shoes were the least rated dengue preventive measures in the pre-test
while wearing shoes and usage of fans to reduce mosquito were the least chosen dengue
preventive measure in the post-test.
Rating of importance to carry out dengue fever preventive measures when away for holidays
were evaluated in the pre-test and post-test. The scores ranged 0 to 4 (0= Very important, 1=
Important, 2= neither important nor unimportant, 3= Unimportant, 4= Very unimportant).
Sealing off all gully traps (M= 0.89, SD= 1.079), sealing off all floor drainage sites (M= 0.90,
SD= 1.011) and storage of water in tightly sealed containers (M= 0.94, SD= 1.045) were highly
rated as the important dengue preventive measures to carry out when away for holidays in the
pre-test (n=63). In addition, removal of all source of stagnant water (M= 0.40, SD= 0.558),
inspection of drains for potential blockage (M= 0.42, SD = 0.530) and cover all toilet bowls (M=
0.45, SD= 0.622) were rated highly in the post-test (n=60). However, clearing drains from leaves
was rated the least important dengue preventive measures to carry out when away for holidays in
the pre-test (M= 1.71, SD= 1.237) and post-test (M= 0.73, SD= 0.899).

Dengue health education exposure

Dengue is not included in the school curriculum based on the results collected in the pre-test and
post-test. The results also showed that there was no one school which organised dengue related
campaign both in the pre-test and post-test.
There were different type of sources of dengue information obtained by the subjects in the pre-
test and post-test. Television (93.7%, 93.3%), newspaper (90.5%, 88.3%) and internet (73%,
78%) were the commonest source of dengue information. However, dengue campaign (4.8%,
23.3%) and others (12.7%, 6.7%) were the least common sources of dengue information. Others
included hospital, family and friends.
Relationship between health education and knowledge on dengue fever and preventive
measures
The effective of health education was compared to the level of knowledge on dengue fever and
preventive measures as demonstrated in the pre-test and post-test data. Paired t-test with the
significant confidence of 0.05 was utilized to determine the effectiveness of health education on
knowledge of dengue fever and preventive measures among the subjects. There was a statistical
significant difference in the scores for pre - test (M= 60.44, SD= 23.087) and post - test (M=
76.55, SD= 15.508); t (59) =-8.635, p-value = 0.000 which is <0.05, 95% with the confidence
interval (CI) of (54.48, 66.41) and (72.54, 80.55) respectively. Therefore, the null hypothesis was
rejected.
DISCUSSION
Knowledge on dengue fever
The pre-test study results show that 88.9% subjects heard of dengue which is similar to the
results of a study conducted by Al-Dubai, et al 89.7%.15 Nevertheless, the percentage was
relatively higher compared to 62.5% subjects heard of dengue in a study conducted by Paul and
77% subjects in a study by Dhimal, et al.16,17 Even though 88.9% subjects heard of dengue but
only 60.3% understood that Aedes mosquito is the carrier of dengue fever and mosquito bite
transmitted dengue fever (58.7%) in the pre-test which is supported in the study by Bota, et al,
they reported that only 50% answered Aedes mosquito as the carrier correctly out of 94.4%
subjects who heard of dengue.19 However, the percentage rose to 85% from 60.3% for Aedes
mosquito and 85% for mosquito bites as dengue transmission in the post-test. In this study,
49.2% subjects pointed 7 p.m. to 9 p.m. as mosquito biting time and 31.7% subjects mentioned
mosquito biting time from 6 a.m. to 8 a.m. and 7 p.m. to 9 p.m. in the pre-test. This result is also
similar with Bota, et al, Neupane, et al and Yboa and Labrague.18-20 Nevertheless, 85%
subjects had better understanding about the correct mosquito biting time after the health
education which was appropriate to choice the best dengue preventive measures.19,21
Only 61.3% subjects have understanding about dengue signs and symptoms. Therefore, it is vital
to improve the awareness of dengue knowledge among school children. In the post-test, the
finding of at least 84.3% subjects were able to perceive dengue signs and symptoms which was
similar finding in the post-test study done by Suwanbamrung.22
In the study conducted by Bota, et al, the subjects essentially had no clear image of mosquito
breeding grounds (9.9%).19 However, in comparison with this previous study, 83.4% subjects
had clear idea about the possible mosquito breeding grounds in the pre-test and 95.7% in the
post-test. Most subjects were aware that the tray under the fridge, water container, flower pot
trays, an opened water tank, roof gutter, an abandoned tyre and in the garbage could be breeding
grounds for Aedes mosquito. This result had similar findings as Neupane, et al.20
It is crucial to promote awareness and provide thorough health education among the school
children. This is where health belief model is related; the element of perceived severity refers to
individual’s beliefs and perception about the severity or seriousness of a disease based on
medical knowledge which could create a general effect in his or her life.12
Knowledge on dengue fever preventive measure
The pre-test finding showed that mosquito repellents were highly rated as dengue preventive
measure followed by mosquito bed nets and wearing long pants. Static and stagnant surfaces are
the attraction breeding grounds of mosquito.15,18,19,22 Hence, it is relevant and significant to
educate the subjects regarding the importance of stagnant surfaces removal to prevent potential
mosquito’s breeding ground. Nonetheless, the removal of all source of stagnant water was the
highest rated after health education followed by inspection of drains for potential blockage and
cover all toilet bowls.
Dengue health education exposure
Comprehension of dengue fever preventive measure is a requisite to prevent dengue fever. But,
dengue fever is not a part of school curriculum syllabi in the learning. All subjects did not
receive any dengue related health information in the last 3 months according to the data in the
pre-test (100%). This result corresponded to the findings in Suwanbamrung, Bota, et al and Isa,
et al.11,19,22 All subjects did not engage themselves in any dengue prevention activities or
health promotion activities before the conduction of this study. Television, newspaper and
internet were the prevalent source of dengue health information in this study.
Relationship between health education and knowledge on dengue fever and preventive
measures
Generally, subjects had better understanding of dengue fever and dengue preventive measures
after health education. There was a significant difference statistically in the scores for pre - test
(M= 60.44, SD= 23.087) and post - test (M= 76.55, SD= 15.508); t (59) = -8.635, p-value= 0.000
which is <0.05. Therefore, the null hypothesis was rejected. Total commitment of dengue
preventive measures obliges good foundation of dengue knowledge in which health education
comes into place. There is necessity to expose dengue education as part of school curriculum to
promote dengue awareness.
CONCLUSION
School students could be the additional resources and mediators to plead for meticulous dengue
fever preventive measures. Hence, health education in the high school level is necessary.
ACKNOWLEDGEMENTS
The researchers express their deepest gratitude to the Head of Nursing Division, International
Medical University (IMU), Associate Dean of IMU Research Lab, and Deputy Co-Chairman,
IMU Joint-Committee on Research and Ethics for reviewing the research proposal and approving
the research fund. The researchers are deeply indebted to the Principals of the Private High
Schools for granting us the permission to conduct pilot study and data collection, respectively.
All the friends and family members of the researchers are greatly appreciated for their constant
support through this project.